Renown Regional Medical Center
Trauma / Surgical Intensive Care
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Guideline: Traumatic Aortic Injury
Adapted from clinical practice guidelines of the Society for vascular surgery.*
*In developing these guidelines The Society utilized The grading of recommendations Assessment, development, and evaluation system (GRADE) The following guidelines should be regarded as grade 2 recommendation with level C evidence
Diagnosis:
1. CT chest with IV contrast and trauma/aortic protocol.
2. Equivocal studies: Formal angiogram in operating room hybrid suite.
3. Transesophageal echo: Cardiac anesthesia (boarded in cardiac echo) in rare cases where the ascending aorta is in question.
4. Trauma surgeon, will consult vascular surgery for positive or equivocal results.
Resuscitation strategy/medical management
1. Aggressive BP Management
a. Beta-blocker, followed by esmolol drip when available
b. Invasive arterial monitoring and admission trauma ICU
2. Pulse Reduction Therapy
a. Maintain mean arterial pressure below 85
Surgical Intervention
1. TEVAR (Thoracic Endovascular Aortic Repair) preferred over open repair
2. Open Repair – Reserved for patients with poor anatomy/ poor candidates for endovascular repair including those who are rapidly hemorrhaging into the pleural select
Classification scheme used for treating blunt aortic injury
1. Intimal tear – absence of contour change and intimal defect and/or thrombus <10mm in length and width
a. Medical management with close surveillance
b. Close surveillance includes repeat imaging (CTA) within 24-48 hours based on clinical condition
2. Large intimal flap – absence of contour change and intimal defect/thrombus > 10mm
a. Consideration given to medical management but most are repaired with TEVR
3. Pseudoaneurysm – presence of external contour abnormality and contained rupture
a. TEVR Repair within 24 hours baring serious other injuries
b. Delayed Repair based on clinical condition
4. Rupture – external contour abnormality and free contrast extravasation
a. TEVR repair preferred
b. Open repair for patients who are not candidates for endovascular repair
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Timing of endovascular aortic repair.
1. Type one injury (intimal tear): Observation with repeat CT scan in 24-48 hours
2. Type II (intramural hematoma) and type III (pseudoaneurysm) urgent repair within 24 hours.
3. Emergent repair for grade 4 (free contrast extravasation).
a. Under most circumstances patient's with significant intra-abdominal hemorrhage will undergo laparotomy and control of abdominal hemorrhage prior to repair of the aorta.
Age and choice of repair: TEVAR is a repair choice in young patients.
Thoracic endograft
1. Appropriate grafts will be available in the endovascular suite. A best device. Has not been determined. The operating room will supply grafts, which match vascular surgeon, credentials.
Management subclavian artery during zone to coverage
1. Selective revascularization of the subclavian artery.
2. The LSA is covered approximately 30% of cases requiring TEVAR. If the LSA is covered. Intraoperative right vertebral artery angiogram can assess adequacy of the posterior circulation. If the right vertebral artery is in adequate with or without an intact circle of Willis consider revascularization of the subclavian artery.
Systemic heparinization:
1. Routine heparin. Consider a lower dose than in the elective TEVAR.
2. Consider no heparin in select cases such as those with extraordinary bleeding. Risks, such as severe pelvic fractures or significant intracranial hemorrhage.
Ongoing management and followup
1. Patients are tracked by the nurse navigator for the Renown Center for Vascular Health
2. Follow-up arranged in the Vascular Center for health.
3. Cardiovascular risk factors and aggressive risk reduction strategies are instituted by a vascular medicine specialist.
4. Patients are enrolled in a lifelong endograft surveillance program through the Renown Center for Vascular Health. Graft complications, will be referred to the operative vascular surgeon.
References:
Lee. J Vasc Surg 2011; 53:187-92
Demetriades. JACS, 214.3 (2012) 247-259
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Initiated: 01/27/2014
Reviewed / Revised: